PURPOSE:The purpose of this study is to elucidate factors associated with flap salvage and examine the efficacy of an updated flap monitoring protocol.METHODS:A retrospective chart review was performed on free flaps performed from January 2005 - July 2014. The institutional floor protocol was initially as follows: q1 hour flap checks for 48 hours then q4 hour flaps checks until discharge. Following the published review of the flap monitoring protocol, flap check intervals now do not exceed two hours. The primary endpoint, successful salvage, was defined as any flap that did not result in total loss.RESULTS:3,660 flaps were examined and 79 take-backs for delayed microvascular compromise were identified. Preoperative factors were examined amongst those flaps which were salvaged versus those which failed. The mean time until take-back (p<0.001), presence of thrombophilia (p=0.001), and chronic hypertension (p=0.05) were factors predictive of unsuccessful salvage. The revised protocol has resulted in patients returning to the operating room earlier postoperatively (p=0.044). Complete mechanical thrombectomy was the only intraoperative maneuver found to be efficacious and only in cases of arterial compromise. Preoperative thrombocytosis on screening lab work was predictive of failed venous salvage (p=0.06). Patients treated with aspirin following initial reconstruction were salvaged at higher rates in the event of a subsequent venous thrombosis (100 percent versus 63 percent).CONCLUSION:The modified floor monitoring protocol resulted in earlier return to the operating room and routine antiplatelet therapy may be an underutilized strategy in the event of a venous thrombosis.